Quality Improvement

Project -
Heparin Administration
Dennis Quaids Story

Jennifer Fine, Nirosha Gnanasegarane, Linnae Shahbaz,

& Arianna Villa
11/2/17
Background
Dennis and Kimberly Quaid gave birth to twins Nov. 8, 2007
9 days later, they were admitted to Los Angeless Cedars-Sinai Hospital
for a staph infection
Nov. 19, 2007 - the twins mistakenly received two 10,000 unit heparin
doses (each 1,000 times stronger than normal dose)
Protamine sulfate was administered, the twins were closely monitored,
and found no lasting effects
After an investigation, the hospital found the mistake was due to a
labeling issue and the Quaids sued Baxter Healthcare Corporation for
negligence
In early 2008, the Quaids established the Quaid Foundation that calls
hospitals to enforce bar coding and scanning patients wristbands
Manpower Methods
No 6 rights of med
No recall on administration
packaging
Documentation
Lack of NO Double RN
communication check of high
risk meds

Effect =
Pyxis withdrawal Twins
received
Similar overdose of
packaging of heparin
Hep-Lock different doses

Machines Materials
Root Cause Analysis
Look-alike labels and
Nurse negligence in Twins receiving two
following six rights of LED TO..
overdoses of
medication
administration Heparin in an 8 hour
period

Identical Labels: Both 10 units and 10,000 units of Heparin come in 1 ml vials with similar labels.
Negligence of pharmacy technicians: Two pharmacy technicians delivered 100 counts of 1 ml vials
containing adult dosage of Heparin 10,000 units/ml instead of pediatric dosage 10 units/ml.

Negligence of nurses: Failure to check the dosage by nurses during medication administration.
Mistake committed twice as two adult doses given at 8 hour intervals.

Absence of backup system: No double checking or computer scanning to pick up human errors.

Multiple person error: Problem in medication stocking, distribution and administration.

 Actions to prevent further occurrence

1. Redesign packaging with different appearance, size and shape

(STRONG)
2. Double RN check for any administration of heparin (STRONG)
3. Implementation of computer barcode scanning (STRONG)
4. Increase staffing which will improve the quality of stocking,
distribution and medication administration (INTERMEDIATE)
5. Administer heparin from pre-loaded syringes: Wrong dosages
were given from vials. (INTERMEDIATE)
6. Using saline as much as possible to flush IVs (WEAK)
Outcome Measures

N = Number of medication errors after

implementing bedside barcoding on the unit.
D = Total medication administrations on the unit.
Threshold = 95% reduction in errors
Date/Time = The collection will be monitored for
three months.
Outcome Measures Type:
Root Cause Outcome Measure:
Effectiveness Measure:
Three months following the implementation of
bedside bar coding, the number of incidents of
patients receiving the incorrect medication
resulting in medication errors will be reduced by
95%. The numerator will be the number of
medication errors after implementing bedside
barcoding on the unit.
Stakeholder Analysis
Internal Stakeholders: External Stakeholders:

Unit Nurses Baxter Healthcare

Unit Physicians Corporation
Patients (manufacturer of
Pharmacy Heparin)
Nursing Managers Other Heparin
Hospital Senior manufacturers
Management Community hospitals
Insurance companies
 Force Field Analysis
Forces FOR Change Forces AGAINST Change
(Driving Forces) (Restraining Forces)

Cost of implementing
Patient safety change
technology
Nursing safety med labeling
training hours
Hospital protection
from lawsuits, Nursing resistance to 2
negligence claims nurse check, additional
training, time for med
administration

Strategies to mitigate restraining forces:

Cost comparison (lawsuits/negligence vs. change costs)
Incentivize training sessions (offer lunch or dinner w/training)
Have parents of infants speak with unit staff to explain impact of near miss
REFERENCES
1. Grant, M. (2010). Dennis Quaids quest. AARP The
Magazine. Retrieved from:
https://www.aarp.org/entertainment/movies-for
-grownups/info-07-2010/dennis-quaid-wants-t
o-save-your-life.html

2. US Department of Veteran Affairs. VA root cause

analysis tools. Retrieved from
https://www.patientsafety.va.gov/professionals/onthejob/rca.asp